Autonomic blood pressure control in children and adolescents with type 1 diabetes mellitus.

INTRODUCTION: Increased daytime blood pressure and reduced nocturnal dipping can already be found in children with type 1 diabetes mellitus. We hypothesized that impaired baroreflex sensitivity can cause this abnormal blood pressure behavior in children and adolescents with type 1 diabetes, reflecting an early stage of diabetic autonomic neuropathy. METHODS: In the present study, we monitored beat-to-beat blood pressure and pulse interval non-invasively with portapres in 38 patients with type 1 diabetes (7-18 yr) and 14 non-diabetic subjects (5-17 yr). The Trigonometric Regressive Spectral Analysis was used to assign spontaneous oscillations of blood pressure and pulse interval to defined frequency bands between 0.003 and 1.0 Hz and to calculate baroreflex sensitivity. Correlations with diabetes-specific data like hemoglobin A1c (HbA1c) and with 24-h blood pressure measurements were calculated. RESULTS: The diabetic subjects displayed significantly less variance of blood pressure and pulse interval in the high frequency (HF) bands and a lower BRS. BRS decreased with higher HbA1c and daily insulin dose. We also saw significant changes in spectral variance of blood pressure and pulse interval with these parameters. Patients with higher sympathetic activity (LF/HF-ratio) during daytime measurements displayed more nocturnal dipping. CONCLUSION: Our data evidence impaired baroreflex sensitivity in children and adolescents with type 1 diabetes mellitus. We suggest spectral analysis of spontaneous blood pressure and pulse interval oscillations during night sleep to further pursue the role of baroreflex sensitivity in the etiology of the non-dipping phenomenon in diabetic patients.

[Sleep disorders in infancy--aspects of diagnosis and somatic background]. / Schlafstörungen im Kleinkindesalter--Diagnostik, Differenzialdiagnostik und somatische Hintergründe.

Sleep-related disturbed breathing and parasomnia in very young children are in the focus of epidemiological interest. The cardinal symptom, i.e. snoring, in connection with nocturnal perspiration, mouth breathing, susceptibility to infection of the upper respiratory tract and tiredness during the day or hypermotility, can be an indication of obstructive sleep apnea (OSA). The common treatment is adenotomy unless there is indication of allergic swelling of the nasal mucous membrane. Other anatomic predispositions for OSA must be considered (tonsillar hypertrophy, midfacial hypoplasia, micro- and retrognathia, e.g. in patients with Down's syndrome or patients with preoperated cleft lip face palate). Inhalative nasal corticoids are a possible alternative to adenotomy in light to medium grade cases of OSA. Tonsillotomy is indicated only in serious OSA cases, tonsillectomy is only justified in cases of chronic tonsillitis or more than 4-6 cases of angina in the last 12 months. Treatment with nasal CPAP is tolerated well also in childhood. Patients with central hypoventilation syndromes, insufficiency of the respiratory musculature or obesitas hypoventilation syndrome can usually be ventilated by non-invasive approach using a nasal mask. Patients suffering from parasomnia should always be asked if they snore at night because if OSA is diagnosed and treated, there are very good prospects of curing somnambulism as well. Like with narcolepsy and REM sleep, a close HLA association has also been identified for family somnambulism. In cases of parasomnia which becomes manifest only after very young age frontal lobe epilepsy should be suspected and searched by polysomnographic and simultaneous continuous nocturnal video surveillance. If reversive development or unclear motoric and utterance phenomena are observed, sleep-bound convulsive disorder should be looked for. Syncopal events can require comprehensive cardiological diagnosis, including exclusion of nightly disorders of the cardiac rhythm.

Obstructive sleep apnea syndrome in children: a state-of-the-art review.

Snoring and obstructive sleep apnea are a frequent problem not only in adults, but also in children and adolescents, as can be seen from current epidemiological data. The epidemiology, etiology, diagnosis, and management of obstructive sleep apnea syndrome (OSAS) in adults have been adequately established on the basis of evidential data. As a result of this, both physicians and the public are increasingly aware of OSAS in adults. Although there are numerous parallels between pediatric and adult OSAS, the situation in children differs that in adults. There is a greater variety of symptoms in children with OSAS, diagnosis is often more difficult with serious consequences for growth and development of children. Treatment of OSAS in children is also different from that of the adult patient. There are many possible causes for the development of obstructive sleep apnea in children. These include hypertrophy of the tonsils and syndromes such as Down syndrome, Pickwickian syndrome, Prader-Willi syndrome or Marfan syndrome. OSAS can, however, also be the result of obesity, midfacial dysplasia, retro- or micrognathia, allergic rhinitis or muscular dystrophy. Epidemiological data presented in the literature concerning the incidence of OSAS in children is extremely varied. This wide range is probably due to the fact that snoring may be misdiagnosed as OSAS. The diagnosis of OSAS in children may only be made by considering clinical history (such as rate of growth, tendency to fall asleep during the day, sleep disturbances, susceptibility to infection, etc.), polysomnography (if possible during several nights) and accompanying instrumental diagnosis including cephalometry or laryngoscopy. One of the problems of polysomnography in childhood is that performance and interpretation of the results have not yet been standardized or evaluated for different age groups. Treatment depends on the cause of OSAS and require multidisciplinary management involving the pediatrician, pediatric or adolescent psychiatrist, ear, nose, and throat specialist, maxillofacial surgeons, and neurosurgeons. Adenotonsillectomy (ATE) is the therapy generally chosen if the child has adenoidal vegetations and/or tonsillar hypertrophy. Corrective surgery is possible for rare malformation syndromes. Nocturnal masks for continuous positive airway nasal pressure or procedures for mask respiration are effective in children, but are only used in exceptional cases, such as when ATE is contraindicated or when symptoms of OSAS remain after surgery. The success of pharmacological treatment of OSAS in children has not been evaluated in controlled clinical trials.

[Reliability of home monitoring with event-recording compared with polysomnography in infants]. / Zuverlässigkeit eines Heimmonitors mit Event-Recording im Vergleich zur kontinuierlichen Polysomnographie im Säuglingsalter.

AIM OF THE STUDY: Although reliable recognition of hypoxemia, apnea, bradycardia and tachycardia is absolutely necessary for home monitoring, many commercially available home monitors have not been sufficiently tested for their sensitivity. The purpose of this study was to determine the reliability of the home monitor VitaGuard 3000 by comparing it with the manual evaluation of full polysomnography (polysomnographic system Alice 3). PATIENT AND METHODS: 20 infants (11 males; 9 females) aged between 5 and 40 weeks (12.2 +/- 3.5 weeks, median 10.5) and with a gestational age between 29 and 41 weeks (37.7 +/- 6.1 weeks, median 39.0) were tested using both full polysomnography and, simultaneously, the home monitor VitaGuard 3000. The results were evaluated manually and compared. RESULTS: The monitor system detected 7/51 central apneas, 6/260 desaturations and 7/18 tachycardias. The sensitivity was 13.72% for apnea, 4.23% for desaturation and 38.80% for tachycardia. The reliability of the home monitor for detecting apnea, desaturation and tachycardia was therefore insufficient. CONCLUSION: A polysomnographic reliability test should be mandatory for all home monitoring systems prior to commercial introduction.

[Prevention of sudden infant death in Germany]. / Prävention des Plötzlichen Süglingstodes in Deutschland.

In Germany there are several committed which however haven't got together yet in order to set up a systematic health education campaign. So far the knowledge of other professional fields like that of graphic designers, specialists of communication and public health scientists hasn't been sufficiently used to familiarize nearly all pregnant women, parents, grandparents and babysitters with those known medical subject matters. Hopefully paediatricians, gynaecologists, children's nurses, midwives, breast-feeding consultants, paediatric preventive assistants, consultants for pregnant women who smoke and mothers in general will soon start to get going an effective lasting and possibly nationwide preventive campaign which will be supported by the competent social ministries and financing authorities, self-help groups, graphic designers, specialists for communication and public health scientists. The aim should be to reduce the amount of sudden infant death cases to or even below the level of The Netherlands (minimum figure in 2002: 0.11 SID cases per 1.000 live births). Already in 1972-15 years before the beginning of the Dutch preventive campaign--in former East Germany a ministerial instruction had advised mothers not to let infants sleep on prone position. Historically, the promotion of infants sleeping on prone position seems to have been a tragic break of tradition in the western world in between 1970 and 1990, as infants had been put to sleep almost only on their back during the past centuries. If we compare East and West Germany concerning the influence on the ways of looking after infants since the 1960th of the last century it has become clear that the advice of medical authorities mainly effects the way of nursing regardless of the political system. More and more, paediatricians, gynaecologists, midwives and children's nurses should become aware of this responsibility.

Self-reported organic and nonorganic sleep problems in schoolchildren aged 11 to 15 years in Vienna.

PURPOSE: To estimate the prevalence of self-reported sleep problems, to examine associations among demographic characteristics, familial factors, and sleep problems, and to investigate the association between the symptoms of obstructive sleep apnea (OSA) and nonorganic sleep disorders. METHODS: An anonymous questionnaire with 22 questions was designed. 332 schoolchildren (aged 11-15 years, mean age 12 years and 9 months; median, 12 years; 56% female, 44% male) from two high schools in Vienna were investigated with regard to self-reported symptoms characteristic for obstructive sleep apnea and for parasomnia/insomnia. Data were analyzed by definition of three groups (problem, occasional problem, and nonproblem sleepers, and by calculation of an insomnia/parasomnia sum score). Statistical analysis included nonparametric tests (Mann Whitney-U and Kruskal), Pearson correlation test, and multiple regression analysis. RESULTS: Twelve percent reported at least one sleep problem every night, 76% reported occasional sleep problems, and 12% had no sleep problems. Girls were affected more frequently than boys (p <.01). Children with sleep problems suffered more often from concentration difficulties (p <.05), daytime fatigue (p <.001), and daytime naps (p <.05). Children who snored had nightmares (10% vs. 2%, p <.01), night terrors (4% vs. 1.5%, p <.001), sleepwalking (1.4% vs. 1%, p <.05), and nocturnal awakening (16% vs. 5%, p <.01) more frequently. On multiple regression analysis, 23% of the variability of a defined parasomnia/insomnia sum score had the characteristic OSA symptoms of nocturnal sweating, dryness of the mouth, snoring, hyperactivity, and daytime fatigue. CONCLUSION: 12% of schoolchildren aged 11-15 years reported sleep problems almost every night. The children suffer from daytime fatigue, naps, and concentration difficulties. Nearly one-fourth of the symptoms of parasomnia/insomnia were associated with characteristic signs of OSA, suggesting the importance of a routine clinical investigation in children with so-called nonorganic sleep disorders.